Nov 10, 2020
Introduction: The Scripps Experience With Resilience Skills Training
By Kathryn Bollin, MD
Owing to geography and our subspecialty, faculty and fellows at our cancer center have largely been spared from service on the front line during the current pandemic. Despite this, like every health care institution, we had to adjust our lives almost instantly for the safety and support of our patients, colleagues, trainees, friends, and families. Staff were sent home to work and face-to-face time with patients shifted to screen time. Our beloved clinical learning environment, where staff and fellows engage in patient care together for hours on end, all but evaporated. While the boundaries of work and home life blurred, and the rush to erect support systems fueled us, fear and uncertainty hummed like a revving engine in the background of every conversation.
Almost presciently, our hematology/oncology fellowship introduced a modified version of the 8-week ASCO Resilience Skills Training Program in January 2020 as an effort to proactively address physician burnout. The course concluded 2 weeks before issuing temporary “stay at home” orders to our fellows. Although we originally implemented the course unsure of its potential benefit, as Dr. Farah Nasraty, our third-year and chief hematology/oncology fellow, writes in her essay, its timely rollout has generated a rapid return on our investment. Thanks to overwhelmingly positive feedback from our fellows and the excitement that the course generated across graduate medical education at Scripps, we now plan to provide this vital course to additional training programs this fall, with each hour-long session expanded to 90 minutes.
Putting Resilience Training Into Action: A Fellow’s Perspective
By Farah Nasraty, MD
I have always been comforted by routine. Alarm goes off so I hit the snooze button. Alarm goes off again and I get up for work, do my morning activities, and head off to medical school… to residency… and now to fellowship. Once back home, I spend time with family or friends, eat dinner, watch so-bad-it’s-good television, then go to bed. While this cycle of “rinse and repeat” for a decade of training may sound boring, there was a consistency to my life as a trainee that I relaxed into and actually enjoyed.
Then came COVID-19. Who knew the daily schedule of my trainee life would ever come to such a screeching and sudden halt? One day we were in clinic and the next we were told to stay home for our safety. After we fellows were sent home, we tried to focus on something, as our leadership worked to create some semblance of an education. We soon started to attend virtual tumor boards, cross-institutional didactics, and quickly learned the ropes of telemedicine visits. Together, we found a way to move our world online.
If I stopped here, you might think everything is now tied up nicely in a bow and that nothing important was lost as a consequence of the pandemic. But, of course, that is not the case. Through this reflection I now see all the little pieces of my valuable routine that were lost or changed. These conversations in my head highlight a few:
“You get to work from home! That’s nice, right?”
Sure, but are we working from home or are we living at work? My rinse-and-repeat cycle did not prepare me for this.
“The fellow office is always loud. It must be nice to have some peace and quiet at home.”
Whose home is peaceful during a pandemic? There may be quiet during a video visit or lecture, but the minute I step out of my home office (also known as my bedroom) I am greeted by my husband, also working from home, our two pets, and noise from the dishwasher, the washing machine, and whichever neighbor has decided to take today’s meetings onto their balcony. Hardly quiet or peaceful.
“Okay, but at least you don’t have to commute and can work in your PJs, so what’s the issue?”
I actually like the ritual and formality of preparing for clinic and, more importantly, I like being around my co-fellows who make me laugh and think and help to make the hours fly by. Now, we each sit at home alone or are socially distanced at work. I am left to wonder what my co-fellows are up to behind their hidden video screens, and, when I am the presenter, I feel like I am speaking out into the ether. I didn’t know how important the encouraging nods or even the sleepy, heavy lids of my bored co-fellows were until they went missing.
“The patient volume is lower now so you can actually study between patients—isn’t that what fellows always ask for?”
True, seeing fewer patients allows more study time, but there is something very special about the in-person discussion between a trainee and their attending. Talking through cases in real time and putting the pieces together as a team will always trump reading through articles and algorithms. The real-world experience and teaching points of our attendings are still spoken over the phone but feeling connected was lost.
Reflecting on the impact COVID-19 has had on my days and the lessons from our resiliency course has helped me to realize that my routines and my absolute need to adhere to structure were coping mechanisms against a natural human fear of chaos. They worked well, to a point, to get me through what I predicted would be the singular challenging events during training. Then came COVID-19—certainly not a predictable or linear event. It has brought death, paranoia, anxiety, fear, loss, anger, and chaos to the forefront of our collective conscience. It has separated us from the friends and family who support us during tough times. It has cancelled my personal routine and our communal social rituals like graduations, weddings, and funerals where we come together to share in joy and sadness. It has demanded that I change and learn to be more flexible.
Now that the chaos is settling a little bit, I can see that although events like this pandemic have dire impacts on us all, opportunities emerge, such as the building of a collective resilience. Fortunately for me and my co-fellows, we were already on this track after learning the concept of resiliency training through an 8-week course prior to COVID-19’s arrival. Under the guidance of a licensed clinical social worker specializing in mindfulness, grief, trauma, and relationships, we discussed these topics as well as burnout, boundaries, perfectionism, and self-care.
Two elements of the course, cognitive distortions and self-compassion, have been especially important to me during this uncertain and disquieting time.
It was hard not to catastrophize during the early months of COVID-19. The what-ifs ran on a loop through my head: What if I get sick? What if my parents get sick? What if we can’t return to seeing patients in person? I was constantly waiting for disaster to strike and it was exhausting. What the course helped me recognize was that this way of thinking, while perhaps not entirely unjustified, didn’t change anything about my current situation. We were taught that identifying a cognitive distortion allows you to have more control over the situation and your emotions. Once recognized, we should take time to examine the facts surrounding this distortion. Are any of these perceived disasters happening at this current moment? Often the answer is no. Of course, I may be answering yes in the future, and for that I will bring my other newly learned resiliency skills to bat. But I recognized that spending each day waiting for something terrible to befall me was not a healthy way to get through a pandemic.
Practicing self-compassion, for the first time in my life, became an essential part of my daily routine. During the resiliency course we discussed the importance of self-care, the toxicities of perfectionism in medicine, as well as potential remedies. I now actively remind myself that there are some things I can’t fix; that it is okay to make a mistake; that it is okay to not be the best and the brightest at every given moment of the day; that doctors, too, are human.
I now look forward to being on the other side of this pandemic, to a time when I can use these tools again for coping with the many different kinds of personal and professional challenges ahead of me. I have come to realize that just as lifelong learning is a commitment made by all physicians, so must we commit to honing our resiliency skillset as a lifelong endeavor.
Dr. Bollin is the associate director of the hematology/oncology fellowship program at Scripps MD Anderson Cancer Center. Her clinical and research focus is on cutaneous oncology. Since COVID-19 began, she has been enjoying the extra time in her home office amidst the chaos of her husband and two daughters. Disclosure.
Dr. Nasraty is a third-year fellow at Scripps MD Anderson Cancer Center. Her clinical interests include breast and gynecologic malignancies. When COVID-19 lets up, she aspires to resume her passion for travel; her next stop will be Vietnam. Disclosure.
ASCO Resilience Skills Training Program
The Resilience Skills Training Program aims to improve physician wellness in oncology through a proactive approach. The program targets current trainees to help create a culture change surrounding wellness, burnout, and resilience in oncology. Oncology training programs can access the Resilience Skills Training Program curricula and materials and implement the training at their own institutions, customizing the course for their program’s needs. For example, the Scripps Hematology/Oncology Fellowship Program adapted the course into the following structure:
1. Introduction: Getting to know each other, establishing mutual guidelines of respect, setting the tone, and high-level course overview
2. Cognitive distortions, burnout
3. Mindfulness (experiential, with discussion)
4. Self-compassion, causes and remedies for perfectionism (research review and experiential)
5. Working with difficult patients/families, setting boundaries, practical interventions
6. Grief and loss: Recognizing in self/others, helpful interventions, grief vs. depression
7. Peer-reviewed journal discussion
8. Applying knowledge to clinical situations